Take Home Message: Rehabilitation programs that incorporate early motion, limit
open kinetic chain exercises prior to 6 weeks post surgery with a transition to
normal open kinetic chain exercises, and incorporate neuromuscular training
throughout are best practices during anterior cruciate ligament (ACL) reconstruction
rehabilitation.

Anterior cruciate ligament (ACL) reconstruction
rehabilitation programs are constantly being evaluated to determine best
practices. The Multicenter Orthopaedic Outcomes Network (MOON) group consists of 20 clinicians who are investigating many
lower extremity injury outcomes. At the
beginning of their prospective cohort study (2005) they created an
evidence-based rehabilitation protocol for patients after an ACL reconstruction.
The goal was a program that could be performed in multiple clinical sites
without expensive equipment. The authors
of this systematic review aimed to review literature from 2005 to 2011 for new evidence
behind current ACL rehabilitation guidelines.
The authors determined favorable outcomes from research studies that
promoted early weight bearing and motion, utilized open kinetic chain
activities (short arc quads until 6 weeks post-surgery then unrestricted), and
incorporated neuromuscular training throughout the rehabilitation program. The authors noted that for many areas of ACL
rehabilitation, there are too few studies or not enough high quality studies to
determine best practices in certain areas.
For example, there was not enough evidence to support the use of
continuous passive motion, postoperative bracing, home-based rehabilitation,
neuromuscular electrical stimulation, or accelerated rehabilitation
programs. However, the authors did note
that optimal electrical stimulation patterns are largely unknown. It is important to note that no deleterious
effects were found in the studies that investigated these rehabilitation
components; however, there were also no determined benefits.

The MOON group reinforces ACL
rehabilitation program guidelines that encourage early motion, open kinetic
chain post-6 weeks, and neuromuscular training throughout the rehabilitation
program. The authors noted that there
are many components of ACL rehabilitation programs that are not standardized
(e.g., electrical stimulation parameters, exercise dosing); hence, further
investigation is needed in these areas to establish best practices. It is also interesting to see that
accelerated rehabilitation programs have not proven to be superior to
traditional programs. Oftentimes
athletes and clinicians get focused on how quickly we can “get them back out
there.” The ACL reconstruction and
rehabilitation process has evolved so quickly and it may be that we have
achieved optimal outcomes in the 5 to 6 month return to activities. It would be interesting if the MOON group
would continue to follow these cohorts out to various time points
longitudinally to get an idea of long-term outcomes in addition to the
immediate outcomes. The MOON group may
be able to identify important factors that leave patients susceptible to poorer
long-term outcomes. These findings may
aid in the identification of potential therapeutic intervention windows in
at-risk populations. Ultimately, we should
continue to implement rehabilitation programs early, include neuromuscular
training throughout, and transition from limited to unrestricted open kinetic
chain activities after 6 weeks.

Questions for Discussion: Are
there other rehabilitation components that you think should be considered best
practices post ACL reconstruction?

5
comments:

I just wanted to note that the MOON Group's project information on their website (https://medschool.vanderbilt.edu/orthopaedics/moon-knee-project) notes that they are planning to follow the study cohort at 2, 6, and 10 year post operative intervals. Knowing several of the physicians involved in this study, I'm sure they will provide phenomenal resources for rehabilitation specialists as the data continues to be reported.

I just wanted to note that the project page for the MOON group notes that they will be following the study cohort at 2, 6, and 10 year intervals. Knowing some of the physicians involved in this study, I am certain that they will provide great resources to rehabilitation specialists of all kinds in the near future as this data continues to be collected.

I agree that the accelerated rehab programs are often pursued, but may not be the most beneficial for the athlete. Information regarding the patient outcomes for the accelerated groups would be interesting to see when comparing injury recurrence, functional questionnaires, and/or progressive cartilage degeneration to the traditional programs. I also agree that early weight bearing and motion of the knee is important, as it may have a limiting effect of muscle inhibition that occurs due to positive feedback. It will be interesting to see what outcomes the MOON group receives in the future!!

Hi Stephan, thanks for the comment! You may be interested in Bruce Beynnon's clinical trial with accelerated rehab for ACL injuries (http://www.ncbi.nlm.nih.gov/pubmed/21952714). The authors found that at two years the groups were similar in terms of "clinical assessment, patient satisfaction, function, proprioception, and isokinetic thigh muscle strength". An earlier pilot study by the group found similar biomarker changes as well (http://www.ncbi.nlm.nih.gov/pubmed/15716250). It will be very helpful to see injury recurrence rates and structural changes down the road. Stay tuned! As more long-term results from the MOON cohort are published we'll have them here.

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